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Minimally Invasive Cox-Maze Procedure is as Effective as Median Sternotomy Approach
Matthew R. Schill, MD, Laurie A. Sinn, RN, BSN, Richard B. Schuessler, PhD, Hersh S. Maniar, MD, Ralph J. Damiano, Jr, MD.
Washington University in St. Louis, Saint Louis, MO, USA.

OBJECTIVE: The Cox-Maze IV procedure (CMIV) has been shown to be an effective treatment for atrial fibrillation (AF) when performed concomitantly with other cardiac operations via median sternotomy (MS) or minimally invasive right minithoracotomy (RMT). Few studies have compared these approaches in patients with lone AF. This study examined short- and long-term outcomes with MS versus RMT in stand-alone CMIV at a single institution.
METHODS: Between January 2002 and October 2015, 195 consecutive patients underwent stand-alone biatrial CMIV. RMT was used in 75 patients, MS in 120. Data were prospectively collected and retrospectively analyzed. Outcomes were evaluated using the Chi-square test, Fisher’s exact test, and the Kruskal-Wallis test. Freedom from AF was ascertained using EKG, Holter, or pacemaker interrogation at 3, 6, 12, 24, 36, 48 and 60 months. Predictors of recurrence were determined using multivariable logistic regression.
RESULTS: Of 17 preoperative variables examined, the only significant differences were that RMT patients had a higher rate of NYHA 3/4 symptoms and a lower rate of prior stroke. RMT and MS patients had similar AF duration (84 vs. 67 months, p=NS) and AF type (26/75 vs. 29/120 paroxysmal, p=NS). RMT patients had a slightly smaller LA diameter (4.5 vs. 4.8 cm, p=0.03). There was a higher rate of box lesion completion in RMT patients (73/75 vs. 100/120, p=0.002).
RMT patients had a shorter hospital stay (7 vs. 8 days, p=0.009) and a similar rate of major complications (3/75 (4%) vs. 7/120 (6%), p=0.74). There were no differences in ICU stay or 30-day mortality or in freedom from AF (FFAF) or FFAF without antiarrhythmic drugs (Figure). Significant predictors of AF recurrence at 12 months included a preoperative pacemaker, failure to isolate the posterior left atrium, and NYHA 3/4 symptoms.
CONCLUSIONS: In our experience, lone CMIV via RMT is as effective as MS with a shorter hospital stay. Expanded use of a minimally invasive approach is encouraged and is our procedure of choice for lone AF.

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